Provider Demographics
NPI:1801309778
Name:2083 THERAPY, LLC
Entity type:Organization
Organization Name:2083 THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:IV
Authorized Official - Credentials:
Authorized Official - Phone:601-849-6440
Mailing Address - Street 1:1392 W GOVERNMENT ST STE C
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-3049
Mailing Address - Country:US
Mailing Address - Phone:601-824-8814
Mailing Address - Fax:
Practice Address - Street 1:1392 W GOVERNMENT ST STE C
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-3049
Practice Address - Country:US
Practice Address - Phone:601-824-8814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1109164OtherBUSINESS LICENSE